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Client Family Intake Process

Dear Parent or Caregiver:

Thank you for your interest in our services. We look forward to meeting with you. Please send in the following information at least a week prior to the evaluation:


1.  Completed Intake Forms, Medical History, Sensory History (OT only)
2.  Signed Consent Forms
3.  Prescription from your child’s physician: Completed Prescription Form (Speech Therapy) or OT & PT Form
4.  Other relevant reports such as current evaluations, the IEP or Neuropsychological evaluations
5.  Copy of your insurance card (both front and back)  

Click here to review our Client Family Handbook.

If you are a member of an HMO or receive services through Child and Family Connections, we will also need your referral or authorization.  It is necessary to receive these completed forms prior to the evaluation or starting therapy in order for us to best meet each child’s needs. This allows for review of your child’s file, determination of assessment tools, and the planning of sufficient time to ensure the evaluation is as comprehensive as possible.  If you had a recent evaluation, this will be used in the determination of the child’s goals. 

As a reminder, the range of fees for each evaluation is $200 to $800  for Physical, Occupational, and/or Speech-Language Therapy evaluations (fees vary depending on the age of the child and the type of testing needed and includes write-up time). Fee assistance may be available upon request.

Please direct all billing questions to our Financial Services Department at 630.282.2028. Our policy requires that all co-pays be paid on the date of service. Many insurance carriers do require pre-authorization prior to an evaluation.  As a courtesy to you, our Client Financial Services Department will verify your insurance benefits, but please be aware that insurance verifications are not guarantees of payment by your insurance carrier.

If you have any questions prior to your appointment, please do not hesitate to call. Diane may be reached at 630.282.2022 or via email: DLDixon@EasterSealsDFVR.org.  Her fax number is 630.620.9525.

Assistive Technology: Client Intake Process

We are pleased to be able to offer you assistive technology services. It is important in beginning our work with you that the forms below be filled out and sent back to us as soon as possible. You need to return completed forms in order to begin the process.

When returning your information, also enclose copies of any recent therapy reports, evaluations, etc. These are important to provide us with background information. Scheduling of the appointment will take place after receipt of all information.

Complete and return the following information as soon as possible:

Background Information Questionnaire
Patient Registration Form
Consent Forms
• Cancellation or No Show Form
• Service Agreement Form
• Any current (last year or so) school reports (IEP) or therapy reports
• A prescription for “Assistive Technology Speech and OT Evaluation and Services” with a diagnosis and diagnosis code, Also the Completed Prescription Form
• Primary Insurance billing information – a copy of an insurance card front and back
• Secondary Insurance billing information- a copy of front and back of card
• Or a letter from payer authorizing payment and where to send bill

Cost of the evaluation or consultation (whichever you have requested) is detailed on our AT Fee Explanation Sheet and is due the day of the evaluation. If billing is to take place, please contact our billing department at 630.620.4433.

At the time of your first appointment the individual to be evaluated will meet with a technology therapist and an occupational therapist. Off-site evaluation appointments are made only under special circumstances and may involve a delay in scheduling as well as an additional fee.

The evaluation/consultation is quite informal and families as well as staff are encouraged to attend and participate. Since the entire evaluation or consultation may take anywhere from one to three hours, you may want to bring along a snack/drink for the individual being seen.

A report is written typically two weeks to 30 days after your first appointment. After you receive a copy of the recommendations, our staff will assist you in following the recommendations.

Thank you and, if you have any questions, please contact our department assistant, Beth Walkington at 630.261.6210.

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